How Do We Know When A Loved One Is Dying?
One of the most common questions hospice nurses and staff receive is, “How will we know when they’re dying?” It’s challenging not to have a clear answer to the question. We never know if a person is truly dying until they die. Everyone’s journey and transition between living and dying are different.
However, what we can do is educate families about the dying process and some of the common signs that indicate a person is actively dying. Again, this won’t be a day, hourly, or minute prediction. Instead, recognizing these signs and being willing to face them with an open heart can completely transform an individual and family’s story.Signs A Loved One Is Dying
To be clear: when we’re talking about the signs a person is dying, we’re speaking of a long-term death, as opposed to sudden death (unpredicted heart attack, aneurism, car accident, etc.) Most of the signs a person is dying occur in stages, some of which arise years and months before they die. Because our culture tries to ignore these signs or pretend that all medical issues can be fixed (they can’t), individuals and families are often shocked when death comes far faster than they were prepared for. This can lead to devastating emotional consequences, including not being prepared for all of the physical, mental/emotional, and practical aspects of dying and after-death care. The better able you are to have conversations about end-of-life, dying, and preparing for the future, the less stressful the process will be.Years & Months Before Death: The Diagnosis
Most people die from a progressive disease or old age. In these cases, the signs a person is dying can start months or years beforehand. For many, it starts with an initial prognosis or diagnosis. You have chronic heart disease, cancer, Parkinson’s, ALS, COPD, etc. Yes, there are treatments. Yes, you can take medication to notably minimize symptoms and side effects and to extend your quality of life. The fact remains that in most cases, that diagnosis is the first sign that you are dying. Now, we’re all dying, and (in most cases) none of us know the exact “how” of the matter. A loved one may have a stage 4 cancer diagnosis that has you reeling, and they outlive you because you have a sudden heart attack or are hit by a car while crossing a street. None of us ever really know. However, a terminal diagnosis should serve as a wake-up call. Being diagnosed with a disease that may be curable/treatable but may not is also a chance to prepare. An 80th, 85th, or 90th birthday is another sign you’re closer to dying than not. You and your loved ones are best served by recognizing this is “the first sign you’re dying,” and begin making comprehensive end-of-life plans that honor body, mind, and spirit. Rather than being scary or heartbreaking (which it may be at some level), we can guarantee this process will remove a huge sense of dread and alleviate stress, improving your quality of life. This is also a good time to reach out to hospice and palliative care agencies in your area so you can begin taking advantage of their invaluable support services.Months & Weeks Before Death: Lack of Appetite and Interest
In the months and weeks before death, many clients lose their interest in a range of things – most notably food and the outside world.Lack of appetite
This typically starts by consuming smaller and smaller portions, or they may skip some meals altogether. Over time, they may only want things like ice cream, yogurt, smoothies, or simple broths. Finally, in the weeks and days before death, they may not want to eat at all. Lack of appetite is completely normal. Your loved one’s lack of appetite or disinterest in food is one of the hardest things to stand by and support. Our culture equates food with nourishment, comfort, and love. In some cases, preparing, serving, and sharing meals and snacks together may be the only way you’ve “enjoyed life” together since they started dying. Never force someone to eat if you know that they are in their last months or weeks of life. This is typically the body’s way of saying, “I don’t process food very well anymore. It takes a lot out of me to digest food and much of it isn’t digesting anyway.” Forcing someone to eat who doesn’t want to can lead to severe constipation or intestinal/g.i. blocks that are painful and stressful to treat. Instead, offer food regularly – but don’t take the “no thank you” personally. They are not suffering from eating. Instead, you may cause suffering by forcing or guilting them into eating.Lack of interest in the outside world
This varies from person to person. Some clients watch football games the day they die, and others stop watching their favorite sports months or weeks before they die. In most cases, we notice a direct correlation between the level of need for inner processing and the level of outside engagement. The more personal and emotional work a loved one is doing on their own (or with the support of a spiritual counselor, therapist, hospice nurse, or loved ones) to work through their life, memories, fears, unresolved situations or emotions, etc. – the less likely they are to participate in the outside world. Remain open to their needs. This is also a good time to let them know the things you want them to know before they are no longer physically available.Weeks & Days Before Death: More Sleeping & Less Engagement
By the time a client is weeks or days away from dying, odds are the efforts to “fix them” have ceased so they can be as comfortable as possible to do some of the most important work they’ll ever do. The labor of dying is not unlike the labor of being born into the world. Odds are they will be asleep more than awake, and our job is to keep them comfortable using balanced medications as needed. Your loved ones should have enough to be comfortable but not so much medication that they are knocked out or unable to communicate when/if they want to. Hopefully, they’ve let you know what they want (or don’t want) around them so the space can be arranged to their wishes.Days & Hours Before Death: The Body Winds Down
Once death is imminent, we say the client is “actively dying” or “in transition.” During this time, you’ll notice several physical indicators that death is near:- Blood pressure will become quite low or may not register (there is absolutely no need to take blood pressure at this point, so feel free to let the “vital sign readings” go so you can be present with your loved one).
- The extremities become cooler and may turn grey or blue.
- The heartbeat becomes very weak and irregular – it’s often very fast or fluttery.
- Breathing can be very congested and seem agitated (as many as 30 to 40 breaths per minute), or it may be very slow and seem to stop at times (as slow as six to ten breaths or less every minute).
- Their words may not make sense (people who are dying often begin speaking in metaphors or in symbolic ways, rather than linear ways, in the days or even weeks before death. Resist the urge to “clarify” or “correct”)
- They may be completely nonresponsive, but they can usually still hear you
- Their mouth may be open (they may make gasping sounds, or you may hear a loud, “scary” rattle – called the death rattle – this is normal), so feel free to use sponges to gently moisten the lips, but there is no need to hydrate at this point.